What amount of cannabis use is needed to develop cannabinoid hyperemesis syndrome (CHS)?

Cannabis Use Patterns Associated with Cannabinoid Hyperemesis Syndrome

Daily or near-daily cannabis use for more than 1 year is typically required to develop cannabinoid hyperemesis syndrome (CHS), with most cases involving use of 4 or more times per week. 1

Diagnostic Patterns of Cannabis Use in CHS

The 2024 American Gastroenterological Association (AGA) clinical practice update provides specific criteria for the cannabis use patterns associated with CHS:

• Duration: More than 1 year of cannabis use before symptom onset 2
• Frequency: More than 4 times per week on average 2
• Intensity: Daily or near-daily use is reported in 68% of cases 1

Most patients with CHS report using cannabis multiple times per day, with a median of 3 times daily in one study 2. Additionally, many patients (72%) report having started cannabis use before age 16 years 2.

Clinical Presentation and Recognition

CHS presents with stereotypical episodic vomiting (at least 3 episodes annually) resembling cyclic vomiting syndrome, along with:

• Cyclic nausea and vomiting (100% of cases) 3
• Abdominal pain (85.1% of cases) 3
• Compulsive hot water bathing for symptom relief (92.3% of cases) 3
• Male predominance (72.9% of cases) 3

Pathophysiology Considerations

The paradoxical nature of CHS is notable - while cannabis has known antiemetic properties, long-term heavy use can trigger this hyperemesis syndrome. This may be related to:

• Overstimulation of CB1 receptors in the brain's dorsal vagal complex 2
• Disruption of the endocannabinoid system's normal negative feedback on the hypothalamic-pituitary-adrenal axis 2
• Altered gastric motility and emptying due to peripheral CB1 receptor activation 2

Diagnostic Challenges

CHS is frequently misdiagnosed, leading to:

• Unnecessary testing and inappropriate treatments 1
• Patient denial about cannabis's role in symptoms 1
• High recidivism rates (>40%) 1

Management Approach

The definitive treatment for CHS is complete cannabis cessation:

1. Acute management:

   • Topical capsaicin (0.1%) application to abdomen 1
   • Olanzapine or haloperidol for symptom control 2, 1
   • IV fluid rehydration for dehydration 1
   • Avoidance of opioids (can worsen nausea) 2

2. Long-term management:

   • Cannabis cessation counseling with addiction treatment referral 1
   • Tricyclic antidepressants (amitriptyline 75-100 mg at bedtime, starting at 25 mg and titrating weekly) 2
   • Co-management with psychiatry for patients with comorbidities 1

Important Caveats

• Unproven strategies like switching to lower THC/higher CBD formulations or using edibles instead of smoking lack scientific validation 1
• Symptom resolution typically requires complete abstinence for at least 6 months or a duration equal to 3 typical vomiting cycles 2, 1
• The increasing potency of cannabis products (higher THC concentration) may be contributing to rising CHS prevalence 4
• CHS should be considered in the differential diagnosis for any patient with cyclic vomiting who has a history of long-term cannabis use to avoid unnecessary and expensive diagnostic workups 5, 6

The definitive diagnosis of CHS is established when symptoms resolve after cannabis cessation, which occurs in 96.8% of cases 3.